49 permit and applications U
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FEE 6 ' V S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratinu for fizpuial 3Slurkn Jnuntrurtinu hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an lndit idual Sewage Disposal
System at:
m . say
Vr�tiJ.NArerI
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building _.
Other fixtures
Design Flow
Septic Tank—Liquid ctnaci
Disposal Trench—No.
Seepage Pit No
Other Distribution box (
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Address
Size Lot Sq. feet
Fepansion Attic ( ) Garbage Grinder ( )
No of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total d
gallons Length Width___
Width Total Length
Diameter Depth below inlet
Dosing tank ( )
Performed by
ily flow gallons-
_. Diameter Depth
Total leaching area sq_ ft.
Total leaching;vet sq. ft.
'ii nutes per inch
minutes per inch
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The 1111d:1-signed further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the bo rd of beak
Signe
ice
Application Approved By
/fn))a pp I�
�.l)l
Application Disapproved for the following reasons: _
No.._ _ �
Issued
au ._ l...I97 re
Permit
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Cnrrtifiratr of fdnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
1r-ter-dim
at
hos been installed in accordance with the provisions of article NI of The State Sanitary Code as described in the
application for Disposal Works Constriction Permit No dated
THE ISSUANCE OF THIS CERTSFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATF Inspector
WHERE APPLICABLE
CHECK OR F
No FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Applirtttinu fur 3linpnnttl ¢knrkn Qtnnntrurtinnrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ") an Individual Sewage Disposal
System at:
Location.Address
Owner
or Lot No.
Address
F Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons.
Septic Tank Liquid capacity Depth
Disposal Trench—No.
gallons per person per day. Total daily flow
gallons Length Width Diameter
Width Total Length Total leaching area
Seepage Pit No Diameter Depth below inlet Total leaching area
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
sq. ft.
sq. ft.
Description of Soil
Nature of Repairs or Alterations—Answer when applicable -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the hodrd of-health, '
Application Approved By
Signed
Date
Date
Date
Permit No - Issued
Application Disapproved for the following reasons•
THE COMMONWEALTH OF MASSACH USETTS
BOARD OF HEALTH
,
L OF i..fOr )•
thrtifiratt of Tomttlitturt
THIS IS TD CRTIFI", That he Individual Sewage Disposal System constructed ( ) or Repaired (
by ,Oga --isaa•Asar
tistaller
at
has been installed in accordance With the p`royisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
rt, ■ - --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Bisponal orks attinstrurtion Prrntit
Permission is hereby granted....
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No
Street
as shown on the application for Disposal Works Construction Permit No Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS